Week 12-14 Diabetes + Genetics Final Document PDF

Diabetes lecture: Week 12 - Typical presentation of diabetes - Jim is a 54-year-old patient who presents to establish care. He has not had a physical in a few years and his spouse encouraged him to be seen. He feels generally healthy but has gained some weight and h...

Diabetes lecture: Week 12 - Typical presentation of diabetes - Jim is a 54-year-old patient who presents to establish care. He has not had a physical in a few years and his spouse encouraged him to be seen. He feels generally healthy but has gained some weight and has some fatigue. He is on no medications and has no significant past medical history. - Vital Signs:  BP:  158/90, HR:  78, BMI: 38 - complications - Leading cause of blindness, kidney failure, and non- traumatic amputations - \~12% with some degree of visual problems - \~39% with some degree of nephropathy - With vascular disease, accounts for 54% of nontraumatic amputations - 50% of people with DM have neuropathy at some point - Cardiovascular Disease - Causes 2/3 of deaths in people with diabetes - Twice as likely as non- diabetic patients to have CVD - Common comorbidities - Hypertension - Dyslipidemia - Cardiovascular disease - Kidney disease - Nonalcoholic fatty liver disease - Osteoarthritis - Obesity - Sleep apnea - Depression - 3 Ps of diabetes: polyuria, - polyphagia, - polydipsia - - Left: type 1- rapid onset  - Right: type 2- insidious onset  - Type 1 diabetes - Destruction of the beta cells of the pancreas -- absolute insulin deficiency - Genetic predisposition -- there are multiple mutations/locations that are associated with T1DM, but few people develop T1DM - Specific HLA (human leukocyte antigen) alleles present in 90% of people with T1DM - Some shared genetic predisposition to celiac disease - Increased risk in close relatives (50% in identical twins) - Triggers -- perinatal factors, viruses, diet - Large geographic variation (Scandinavian Europe -  - Type 2 Diabetes - -  - Other forms of diabetes - Gestational Diabetes - High risk for fetal macrosomia - Mom and baby at risk for development of T2DM later in life - Pancreatogenic (Type 3c) - Cystic fibrosis - Pancreatitis - Pancreatectomy - Drug or chemical induced - Corticosteroids - Thiazide-type diuretics - Atypical antipsychotics - Maturity onset diabetes of the young - Autosomal dominant mutation to beta cell receptors - APPROPRIATE DIAGNOSTIC TESTS - Screening - Fasting plasma glucose - 2 hour post oral glucose tolerance test - Hemoglobin A1c - Diagnostic  - Casual glucose - Fasting glucose - Hemoglobin A1c - In the absence of unequivocal hyperglycemia diagnosis requires two abnormal test results from the same sample or in two separate test samples - Begin screening at age 45 for the general adult population - If normal, repeat every 3 years - In those with increased risk of DM, initial screening should begin at identification of these risk factors and repeated in 3-year intervals if normal - BMI \>25 (\>23 in Asian Americans, overweight women considering pregnancy - Pre-DM -- A1c or IFG, IGT - People with HIV when starting ART or when changing regimens - -     Supportive Lab Tests Blood glucose must be high to check a c. peptide  Latent Autoimmune Diabetes in Adulthood (LADA) - Adult-onset form of autoimmune diabetes, often misdiagnosed initially as T2DM - Slowly progressive insulin dependence - progressive autoimmune beta cell destruction Differentiating the Types of DM   **Feature**​ **T1DM**​ **LADA**​ **T2DM**​ --------------------- ------------------------- ------------------------- ------------------------- Age at onset​ Childhood, adolescence​ \>30 years​ Adulthood​ Onset​ Very acute​ Rarely acute​ Slow​ Autoimmunity​ Severe​ Present​ Not present​ Ketosis​ High risk​ Rare​ Rare​ Insulin resistance​ None​ Possible​ Severe​ Beta cell function​ Severe decrease​ Decrease​ Increased or no change​ Insulin dependence​ At onset​ \>6 months after onset​ Years after onset​ Key Points  Determine form of diabetes​ Screen for/detect complications​​ Determine best management strategy (more to come in N810)​​ Establish baseline health​​ Assess health maintenance needs History  - Symptoms of hyperglycemia, hypoglycemia - Onset of symptoms - Previous treatment for DM - Duration of DM - Recent lab results and TRENDS - Known complications - Impact on ADLs - -  - Questions to ask at follow-up visits - Any new concerns? - Make changes recommended? - Any adverse reactions? - hypoglycemia - Review blood sugar log - Revisit lifestyle modifications - Adherence - Symptoms associated with complications  REVIEW OF SYSTEMS (ROS)  - General: malaise, weight change  - CV: chest pain, dyspnea, orthopnea, edema - GI: GI distress (common ADE), neuropathy, absorption disorder - Endocrine: 3 Ps (polyuria, polydipsia, polyphagia), blurry vision - Extremities: numbness, tingling, sores, temp, pain, deformities Physical Examination - Skin: acanthosis, dermopathy, tinea/yeasts - HEENT: especially carotids, thyroid, mouth/dentition  - Eyes: visual acuity, fundoscopic examination - Heart: arrhythmias, LVH, signs of heart failure - Lungs: signs of heart failure - GI -- hepatomegaly, assessment of GI complaints  - Peripheral vascular: pulses, skin - Neurological/Feet: monofilament exam annually, observation of feet at EACH visit for wounds, infections, deformities - Neurological Assessment: Monofilament testing - Vital signs - Weight and BMI: look for loss or gain - BP: Goal is 140/90 OR LESS for most; 130/80 for higher ASCVD risk - A1c: Goal is \ - Elevated A1c best indicator of risk for development of complications (UKPDS)​ - 1% reduction in A1c about 30% reduction in complications - - Self-monitoring Blood Glucose - Schedule depends on treatment and patient​ - A1c insufficient to identify trends and adjust treatment​ - Goal FBS: 80-120​ - Goal 2 hr pp: 100-​ - 150 - Necessary for type 1 diabetics, not necessarily type 2  - Glycemic Assessment - Twice a year in patients meeting targets​ - Four times a year in patients not meeting targets or with treatment changes - Due to glucose bound to RBCs renew q3 months  Self-monitoring  - Shows trends - Shows how food, medication, exercise, and stress affect blood sugars  - Determine effectiveness of regimen Types of glucose monitoring - Continuous glucose monitoring - Real Time: Measure and store BG levels continuously using information gained from interstitial fluid - Intermittently Scanned: Intermittent, patient-driven assessment using information gained from interstitial fluid - Fingerstick glucose monitoring - Intermittent, patient driven assessment using new sample each time - Professional - CGM placed by a clinic and worn for a short period of time for diagnostic purposes Healthcare Maintenance  - Diabetes-related - Ophthalmology:  dilated retinal exam within 6 months of diagnosis of T2DM, then annually; within 5 years of diagnosis of T1DM, then annually - Vaccines:  pneumonia, influenza, covid - Dental care every 6 months - Depression screening - General health:  routine cancer screenings, vaccinations, health monitoring for age Modified Goal Setting A1c goal \